Healthcare Provider Details

I. General information

NPI: 1184789109
Provider Name (Legal Business Name): PAUL T. WILSON-GRILLS ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 SW 136TH ST
BURIEN WA
98166-1214
US

IV. Provider business mailing address

2600 SW HOLDEN ST
SEATTLE WA
98126-3505
US

V. Phone/Fax

Practice location:
  • Phone: 206-257-6600
  • Fax: 206-257-6830
Mailing address:
  • Phone: 206-933-7214
  • Fax: 206-933-7005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP30004839
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: